CARIN Consumer Directed Payer Data Exchange
0.4.0 - STU1
CARIN Consumer Directed Payer Data Exchange
0.4.0 - STU1
CARIN Consumer Directed Payer Data Exchange - Local Development build (v0.4.0). See the Directory of published versions
The profile is used for Explanation of Benefits (EOBs) based on claims submitted by clinics, hospitals, skilled nursing facilities and other institutions for inpatient services, which may include the use of equipment and supplies, laboratory services, radiology services and other charges. Inpatient claims are submitted for services rendered at a facility as part of an overnight stay. The claims data is based on the institutional claim format UB-04, submission standards adopted by the Department of Health and Human Services as form CMS-1450.
The official URL for this profile is:
http://hl7.org/fhir/us/carin-bb/StructureDefinition/CARIN-BB-ExplanationOfBenefit-Inpatient-Facility
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CARINBBExplanationOfBenefit
Summary
Mandatory: 5 elements (8 nested mandatory elements)
Must-Support: 24 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
This structure is derived from CARINBBExplanationOfBenefit
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  ExplanationOfBenefit | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource | |
  identifier | S | 1..* | Identifier | Claim identifier for a claim. (35 ) |
| status | S | 1..1 | code | (140 ) |
 type | 1..1 | CodeableConcept | Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). (16 ) Required Pattern: At least the following | |
  coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
 code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional | |
| coding | S | 1..1 | Coding | Code defined by a terminology system |
| patient | 1..1 | Reference(CARIN BB Patient) | Provider submitted information that can be included on the claim (110 ) | |
| billablePeriod | 0..1 | Period | Identifies the date the patient was admitted/discharged for facility care (18,19 ) | |
 provider | 1..1 | Reference(CARIN BB Organization) | The National Provider Identifier assigned to the Billing Provider. (94 ) | |
| related | 0..* | BackboneElement | Replaced or Merged claim number (112 ) | |
| payee | ||||
| type | 1..1 | CodeableConcept | Identifies recipient of benefits payable; i.e., provider or subscriber (120 ) | |
| party | 1..1 | Reference(CARIN BB Organization | CARIN BB Patient | CARIN BB Practitioner) | Recipient reference (121 ) | |
| careTeam | I | 0..* | BackboneElement | Care Team members EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to a practitioner |
| provider | 1..1 | Reference(CARIN BB Organization | CARIN BB Practitioner) | The NPI of the referring physician. (99 ) | |
| role | 1..1 | CodeableConcept | Function within the team Binding: CARINBB Institutional Claim Care Team Roles (required) | |
 supportingInfo | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by pattern:category | |
 supportingInfo:All Slices | Content/Rules for all slices | |||
  code | 0..1 | CodeableConcept | Patient’s status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). (117 ) | |
 supportingInfo:billingnetworkcontractingstatus | 0..1 | BackboneElement | Indicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101 ) | |
 category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
  coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
 system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus | |
 code | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) | |
| supportingInfo:attendingnetworkcontractingstatus | 0..1 | BackboneElement | Indicates the network status of the attending physician (101 ) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: attendingnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) | |
| supportingInfo:referringnetworkcontractingstatus | 0..1 | BackboneElement | Indicates the network status of the referring physician (101 ) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: referringnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) | |
| supportingInfo:supervisingnetworkcontractingstatus | 0..1 | BackboneElement | Supporting information | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: supervisingnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) | |
| supportingInfo:clmrecvddate | 0..1 | BackboneElement | The date the claim was received by the payer (88 ) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
 timing[x] | 1..1 | date | When it occurred | |
| supportingInfo:typeofbill | 0..1 | BackboneElement | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17 ) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: typeofbill | |
| code | 0..1 | CodeableConcept | Type of information Binding: nubc-type-of-bill (required) | |
| supportingInfo:pointoforigin | 0..1 | BackboneElement | Identifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13 ) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admsrc | |
| code | 0..1 | CodeableConcept | Type of information Binding: nubc-admission-source (required) | |
| supportingInfo:admtype | 0..1 | BackboneElement | Claim Priority (Type) of Admission or Visit | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admtype | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Priority of Admission (required) | |
| supportingInfo:discharge-status | 0..1 | BackboneElement | Discharge Status | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: discharge-status | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Patient Discharge Status (required) | |
| supportingInfo:drg | 0..1 | BackboneElement | Claim diagnosis related group (DRG) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: drg | |
| code | 0..1 | CodeableConcept | Type of information Binding: CMS-DRG (required) | |
 supportingInfo:onadmissiontype | 0..1 | BackboneElement | On Admission Type | |
| code | 0..1 | CodeableConcept | Type of information Binding: Payer Diagnosis Present On Admission Diagnosis Type (required) | |
| diagnosis | S | 1..* | BackboneElement | This is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. (31 ) |
 diagnosis[x] | S | 1..1 | CodeableConcept | A plain text representation of the diagnosis (145 ) Binding: ICD-10-CM Diagnosis Codes (required) |
| type | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: Diagnosis Type -- Inpatient Facility (required) |
| onAdmission | S | 0..1 | CodeableConcept | Used to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. (28 ) Binding: NUBC Present On Admission (required) |
| procedure | 0..* | BackboneElement | Principal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). (24 ) | |
| procedure[x] | S | 1..1 | (Slice Definition) | Specific clinical procedure Slice: Unordered, Open by type:$this |
| procedureCodeableConcept | 0..1 | CodeableConcept | Specific clinical procedure Binding: ICD-10-PCS (required) | |
| insurance | 1..* | BackboneElement | Identifies the primary payer. For use only on secondary claims. (141 ) | |
| coverage | 1..1 | Reference(CARIN BB Coverage) | Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1 ) | |
| item | ||||
| sequence | S | 1..1 | positiveInt | Line identification number that represents the number assigned in a source system for identification and processing. (36 ) |
| revenue | S | 0..1 | CodeableConcept | Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86 ) Binding: nubc-service-line-revenue (required) |
| productOrService | S | 1..1 | CodeableConcept | Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40 ) Binding: AMA CPT and CMS HCPCS Procedure Codes (required) |
| modifier | S | 0..* | CodeableConcept | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41 ) Binding: AMA CPT and CMS HCPCS Modifier Codes (required) |
| quantity | S | 0..1 | SimpleQuantity | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42 ) |
| adjudication | 0..* | (Slice Definition) | The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149 ) Slice: Unordered, Closed by pattern:$this | |
| adjudication:adjudicationamounttype | 0..* | BackboneElement | Amounts | |
 category | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) | |
| amount | S | 0..1 | Money | Monetary amount |
| adjudication:denialreason | 0..1 | BackboneElement | Denial Reason | |
| category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) | |
| adjudication:allowedunits | 0..1 | BackboneElement | Allowed number of units | |
 category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
| adjudication | 0..* | (Slice Definition) | Header-level adjudication Slice: Unordered, Closed by value:category | |
| adjudication:All Slices | Content/Rules for all slices | |||
| category | S | 1..1 | CodeableConcept | Indicates the in network or out of network payment status of the claim. (142 ) |
| adjudication:adjudicationamounttype | 0..* | BackboneElement | Amounts | |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) | |
| amount | 1..1 | Money | Monetary amount | |
| adjudication:denialreason | 0..1 | BackboneElement | Denial Reason | |
| category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) | |
| total | 1..* | (Slice Definition) | Adjudication totals Slice: Unordered, Open by value:category | |
| total:All Slices | Content/Rules for all slices | |||
 category | S | 1..1 | CodeableConcept | Type of adjudication information |
| amount | S | 1..1 | Money | Total amount for each category (i.e., submitted, allowed, etc.) (148 ) |
| total:adjudicationamounttype | S | 0..* | BackboneElement | Amounts |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) | |
| amount | S | 1..1 | Money | Financial total for the category |
| total:inoutnetwork | S | 1..1 | BackboneElement | Benefit Payment Status |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Benefit Payment Status (required) | |
| amount | S | 1..1 | Money | Financial total for the category |
| payment | ||||
| type | S | 0..1 | CodeableConcept | Indicates whether the claim was paid or denied. (91 ) |
| adjustmentReason | S | 0..1 | CodeableConcept | Reason codes used to interpret the Non-Covered Amount (92 ) |
| date | S | 0..1 | date | The date the claim was paid. (107 ) |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit | I | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | ΣI | 0..1 | Meta | Metadata about the resource |
| id | 0..1 | string | Unique id for inter-element referencing | |
 extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| versionId | ΣI | 0..1 | id | Version specific identifier |
| lastUpdated | SΣI | 1..1 | instant | When the resource version last changed |
| source | ΣI | 0..1 | uri | Identifies where the resource comes from |
| profile | SΣI | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
| security | ΣI | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible) |
| tag | ΣI | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example) |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
 modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SI | 1..* | (Slice Definition) | Claim identifier for a claim. (35 ) Slice: Unordered, Open by pattern:$this |
| identifier:claimnumber | SI | 1..1 | Identifier | Claim Number Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| use | 0..1 | code | usual | official | temp | secondary | old (If known) | |
| type | 1..1 | CodeableConcept | Description of identifier Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/IdentifierTypeCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: cn | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| system | 0..1 | uri | The namespace for the identifier value | |
| value | 0..1 | string | The value that is unique | |
| period | 0..1 | Period | Time period when id is/was valid for use | |
| assigner | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | The value that is unique Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| status | ?!SΣI | 1..1 | code | (140 ) Binding: ExplanationOfBenefitStatus (required) |
| type | SΣI | 1..1 | CodeableConcept | Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). (16 ) Binding: ClaimTypeCodes (required) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 1..1 | Coding | Code defined by a terminology system |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| subType | I | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example) |
| use | ΣI | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required) Required Pattern: claim |
| patient | SΣI | 1..1 | Reference(CARIN BB Patient) | Provider submitted information that can be included on the claim (110 ) |
| billablePeriod | SΣI | 0..1 | Period | Identifies the date the patient was admitted/discharged for facility care (18,19 ) |
| created | ΣI | 1..1 | dateTime | Response creation date |
| enterer | I | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim |
| insurer | SΣI | 1..1 | Reference(CARIN BB Organization) | Party responsible for reimbursement |
| provider | SΣI | 1..1 | Reference(CARIN BB Organization) | The National Provider Identifier assigned to the Billing Provider. (94 ) |
| priority | I | 0..1 | CodeableConcept | Desired processing urgency Binding: http://terminology.hl7.org/CodeSystem/processpriority (example) |
| fundsReserveRequested | I | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example) |
| fundsReserve | I | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example) |
| related | SI | 0..* | BackboneElement | Replaced or Merged claim number (112 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| claim | I | 0..1 | Reference(Claim) | Reference to the related claim |
| relationship | SI | 1..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example) |
| reference | I | 0..1 | Identifier | File or case reference |
| prescription | I | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products |
| originalPrescription | I | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller |
| payee | SI | 0..1 | BackboneElement | Recipient of benefits payable |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | SI | 1..1 | CodeableConcept | Identifies recipient of benefits payable; i.e., provider or subscriber (120 ) Binding: Claim Payee Type Codes (example) |
| party | SI | 1..1 | Reference(CARIN BB Organization | CARIN BB Patient | CARIN BB Practitioner) | Recipient reference (121 ) |
| referral | I | 0..1 | Reference(ServiceRequest) | Treatment Referral |
| facility | I | 0..1 | Reference(Location) | Servicing Facility |
| claim | I | 0..1 | Reference(Claim) | Claim reference |
| claimResponse | I | 0..1 | Reference(ClaimResponse) | Claim response reference |
| outcome | ΣI | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) |
| disposition | I | 0..1 | string | Disposition Message |
| preAuthRef | I | 0..* | string | Preauthorization reference |
| preAuthRefPeriod | I | 0..* | Period | Preauthorization in-effect period |
| careTeam | SI | 0..* | BackboneElement | Care Team members EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to a practitioner |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Order of care team |
| provider | SI | 1..1 | Reference(CARIN BB Organization | CARIN BB Practitioner) | The NPI of the referring physician. (99 ) |
| responsible | SI | 0..1 | boolean | Indicator of the lead practitioner |
| role | SI | 1..1 | CodeableConcept | Function within the team Binding: CARINBB Institutional Claim Care Team Roles (required) |
| qualification | I | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example) |
| supportingInfo | SI | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by pattern:category |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) |
| code | SI | 0..1 | CodeableConcept | Patient’s status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). (117 ) Binding: ExceptionCodes (example) |
 timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:billingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Indicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:attendingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Indicates the network status of the attending physician (101 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: attendingnetworkcontractingstatus | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:referringnetworkcontractingstatus | SI | 0..1 | BackboneElement | Indicates the network status of the referring physician (101 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: referringnetworkcontractingstatus | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:supervisingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Supporting information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: supervisingnetworkcontractingstatus | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:clmrecvddate | SI | 0..1 | BackboneElement | The date the claim was received by the payer (88 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example) |
| timing[x] | SI | 1..1 | date | When it occurred |
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:typeofbill | SI | 0..1 | BackboneElement | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: typeofbill | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: nubc-type-of-bill (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:pointoforigin | SI | 0..1 | BackboneElement | Identifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admsrc | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: nubc-admission-source (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:admtype | SI | 0..1 | BackboneElement | Claim Priority (Type) of Admission or Visit |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admtype | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Priority of Admission (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:discharge-status | SI | 0..1 | BackboneElement | Discharge Status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: discharge-status | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Patient Discharge Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:drg | SI | 0..1 | BackboneElement | Claim diagnosis related group (DRG) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: drg | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: CMS-DRG (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:onadmissiontype | SI | 0..1 | BackboneElement | On Admission Type |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: Payer Diagnosis Present On Admission Diagnosis Type (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| diagnosis | SI | 1..* | BackboneElement | This is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. (31 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Diagnosis instance identifier |
| diagnosis[x] | SI | 1..1 | CodeableConcept | A plain text representation of the diagnosis (145 ) Binding: ICD-10-CM Diagnosis Codes (required) |
| type | SI | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: Diagnosis Type -- Inpatient Facility (required) |
| onAdmission | SI | 0..1 | CodeableConcept | Used to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. (28 ) Binding: NUBC Present On Admission (required) |
| packageCode | I | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example) |
| procedure | SI | 0..* | BackboneElement | Principal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). (24 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Procedure instance identifier |
| type | SI | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example) |
| date | SI | 0..1 | dateTime | When the procedure was performed |
| procedure[x] | SI | 1..1 | (Slice Definition) | Specific clinical procedure Slice: Unordered, Closed by type:$this Binding: ICD-10ProcedureCodes (example) |
| procedure[x]:procedureCodeableConcept | I | 0..1 | CodeableConcept | Specific clinical procedure Binding: ICD-10-PCS (required) |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| precedence | I | 0..1 | positiveInt | Precedence (primary, secondary, etc.) |
| insurance | SΣI | 1..* | BackboneElement | Identifies the primary payer. For use only on secondary claims. (141 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | SΣI | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | SΣI | 1..1 | Reference(CARIN BB Coverage) | Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1 ) |
| preAuthRef | I | 0..* | string | Prior authorization reference number |
| accident | I | 0..1 | BackboneElement | Details of the event |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| date | I | 0..1 | date | When the incident occurred |
| type | I | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible) |
| location[x] | I | 0..1 | Where the event occurred | |
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| item | SI | 0..* | BackboneElement | Product or service provided |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | SI | 1..1 | positiveInt | Line identification number that represents the number assigned in a source system for identification and processing. (36 ) |
| careTeamSequence | I | 0..* | positiveInt | Applicable care team members |
| diagnosisSequence | I | 0..* | positiveInt | Applicable diagnoses |
| procedureSequence | I | 0..* | positiveInt | Applicable procedures |
| informationSequence | I | 0..* | positiveInt | Applicable exception and supporting information |
| revenue | SI | 0..1 | CodeableConcept | Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86 ) Binding: nubc-service-line-revenue (required) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | SI | 1..1 | CodeableConcept | Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40 ) Binding: AMA CPT and CMS HCPCS Procedure Codes (required) |
| modifier | SI | 0..* | CodeableConcept | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41 ) Binding: AMA CPT and CMS HCPCS Modifier Codes (required) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | SI | 0..1 | SimpleQuantity | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42 ) |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| encounter | I | 0..* | Reference(Encounter) | Encounters related to this billed item |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | SI | 0..* | (Slice Definition) | The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149 ) Slice: Unordered, Closed by pattern:$this |
| adjudication:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:adjudicationamounttype | SI | 0..* | BackboneElement | Amounts |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | SI | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:denialreason | SI | 0..1 | BackboneElement | Denial Reason |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| reason | I | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:allowedunits | SI | 0..1 | BackboneElement | Allowed number of units |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| detail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Detail level adjudication details |
| subDetail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Subdetail level adjudication details |
| addItem | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | I | 0..* | positiveInt | Item sequence number |
| detailSequence | I | 0..* | positiveInt | Detail sequence number |
| subDetailSequence | I | 0..* | positiveInt | Subdetail sequence number |
| provider | I | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| detail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| subDetail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| adjudication | SI | 0..* | (Slice Definition) | Header-level adjudication Slice: Unordered, Closed by value:category |
| adjudication:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Indicates the in network or out of network payment status of the claim. (142 ) Binding: Claim Adjudication Category (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:adjudicationamounttype | SI | 0..* | BackboneElement | Amounts |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 1..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:denialreason | SI | 0..1 | BackboneElement | Denial Reason |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| reason | I | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| total | ΣI | 1..* | (Slice Definition) | Adjudication totals Slice: Unordered, Open by value:category |
| total:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| amount | SΣI | 1..1 | Money | Total amount for each category (i.e., submitted, allowed, etc.) (148 ) |
| total:adjudicationamounttype | SΣI | 0..* | BackboneElement | Amounts |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | ΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) |
| amount | SΣI | 1..1 | Money | Financial total for the category |
| total:inoutnetwork | SΣI | 1..1 | BackboneElement | Benefit Payment Status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | ΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: Benefit Payment Status (required) |
| amount | SΣI | 1..1 | Money | Financial total for the category |
| payment | SI | 0..1 | BackboneElement | Payment Details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | SI | 0..1 | CodeableConcept | Indicates whether the claim was paid or denied. (91 ) Binding: Claim Payment Status Code (required) |
| adjustment | I | 0..1 | Money | Payment adjustment for non-claim issues |
| adjustmentReason | SI | 0..1 | CodeableConcept | Reason codes used to interpret the Non-Covered Amount (92 ) Binding: PaymentAdjustmentReasonCodes (example) |
| date | SI | 0..1 | date | The date the claim was paid. (107 ) |
| amount | I | 0..1 | Money | Payable amount after adjustment |
| identifier | I | 0..1 | Identifier | Business identifier for the payment |
| formCode | I | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example) |
| form | I | 0..1 | Attachment | Printed reference or actual form |
| processNote | I | 0..* | BackboneElement | Note concerning adjudication |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| number | I | 0..1 | positiveInt | Note instance identifier |
| type | I | 0..1 | code | display | print | printoper Binding: NoteType (required) |
| text | I | 0..1 | string | Note explanatory text |
| language | I | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| benefitPeriod | I | 0..1 | Period | When the benefits are applicable |
| benefitBalance | I | 0..* | BackboneElement | Balance by Benefit Category |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| excluded | I | 0..1 | boolean | Excluded from the plan |
| name | I | 0..1 | string | Short name for the benefit |
| description | I | 0..1 | string | Description of the benefit or services covered |
| network | I | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example) |
| unit | I | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example) |
| term | I | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example) |
| financial | I | 0..* | BackboneElement | Benefit Summary |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example) |
| allowed[x] | I | 0..1 | Benefits allowed | |
| allowedUnsignedInt | unsignedInt | |||
| allowedString | string | |||
| allowedMoney | Money | |||
| used[x] | I | 0..1 | Benefits used | |
| usedUnsignedInt | unsignedInt | |||
| usedMoney | Money | |||
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit | I | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource |
| meta | ΣI | 0..1 | Meta | Metadata about the resource |
| lastUpdated | ΣI | 1..1 | instant | When the resource version last changed |
| profile | ΣI | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
| identifier | I | 1..* | (Slice Definition) | Claim identifier for a claim. (35 ) Slice: Unordered, Open by pattern:$this |
| identifier:claimnumber | I | 1..1 | Identifier | Claim Number Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| use | 0..1 | code | usual | official | temp | secondary | old (If known) | |
| type | 1..1 | CodeableConcept | Description of identifier Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/IdentifierTypeCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: cn | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| system | 0..1 | uri | The namespace for the identifier value | |
| value | 0..1 | string | The value that is unique | |
| period | 0..1 | Period | Time period when id is/was valid for use | |
| assigner | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | |
| value | ΣI | 1..1 | string | The value that is unique |
| status | ?!ΣI | 1..1 | code | (140 ) Binding: ExplanationOfBenefitStatus (required) |
| type | ΣI | 1..1 | CodeableConcept | Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). (16 ) Binding: ClaimTypeCodes (required) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| coding | ΣI | 1..1 | Coding | Code defined by a terminology system |
| patient | ΣI | 1..1 | Reference(CARIN BB Patient) | Provider submitted information that can be included on the claim (110 ) |
| billablePeriod | ΣI | 0..1 | Period | Identifies the date the patient was admitted/discharged for facility care (18,19 ) |
| insurer | ΣI | 1..1 | Reference(CARIN BB Organization) | Party responsible for reimbursement |
| provider | ΣI | 1..1 | Reference(CARIN BB Organization) | The National Provider Identifier assigned to the Billing Provider. (94 ) |
| related | I | 0..* | BackboneElement | Replaced or Merged claim number (112 ) |
| relationship | I | 1..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example) |
| payee | I | 0..1 | BackboneElement | Recipient of benefits payable |
| type | I | 1..1 | CodeableConcept | Identifies recipient of benefits payable; i.e., provider or subscriber (120 ) Binding: Claim Payee Type Codes (example) |
| party | I | 1..1 | Reference(CARIN BB Organization | CARIN BB Patient | CARIN BB Practitioner) | Recipient reference (121 ) |
| careTeam | I | 0..* | BackboneElement | Care Team members EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to a practitioner |
| provider | I | 1..1 | Reference(CARIN BB Organization | CARIN BB Practitioner) | The NPI of the referring physician. (99 ) |
| responsible | I | 0..1 | boolean | Indicator of the lead practitioner |
| role | I | 1..1 | CodeableConcept | Function within the team Binding: CARINBB Institutional Claim Care Team Roles (required) |
| supportingInfo | I | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by pattern:category |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| code | I | 0..1 | CodeableConcept | Patient’s status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). (117 ) Binding: ExceptionCodes (example) |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:billingnetworkcontractingstatus | I | 0..1 | BackboneElement | Indicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101 ) |
| code | I | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:attendingnetworkcontractingstatus | I | 0..1 | BackboneElement | Indicates the network status of the attending physician (101 ) |
| code | I | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:referringnetworkcontractingstatus | I | 0..1 | BackboneElement | Indicates the network status of the referring physician (101 ) |
| code | I | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:supervisingnetworkcontractingstatus | I | 0..1 | BackboneElement | Supporting information |
| code | I | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:clmrecvddate | I | 0..1 | BackboneElement | The date the claim was received by the payer (88 ) |
| code | I | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example) |
| timing[x] | I | 1..1 | date | When it occurred |
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:typeofbill | I | 0..1 | BackboneElement | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17 ) |
| code | I | 0..1 | CodeableConcept | Type of information Binding: nubc-type-of-bill (required) |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:pointoforigin | I | 0..1 | BackboneElement | Identifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13 ) |
| code | I | 0..1 | CodeableConcept | Type of information Binding: nubc-admission-source (required) |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:admtype | I | 0..1 | BackboneElement | Claim Priority (Type) of Admission or Visit |
| code | I | 0..1 | CodeableConcept | Type of information Binding: NUBC Priority of Admission (required) |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:discharge-status | I | 0..1 | BackboneElement | Discharge Status |
| code | I | 0..1 | CodeableConcept | Type of information Binding: NUBC Patient Discharge Status (required) |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:drg | I | 0..1 | BackboneElement | Claim diagnosis related group (DRG) |
| code | I | 0..1 | CodeableConcept | Type of information Binding: CMS-DRG (required) |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| supportingInfo:onadmissiontype | I | 0..1 | BackboneElement | On Admission Type |
| code | I | 0..1 | CodeableConcept | Type of information Binding: Payer Diagnosis Present On Admission Diagnosis Type (required) |
| timing[x] | I | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | I | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| diagnosis | I | 1..* | BackboneElement | This is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. (31 ) |
| diagnosis[x] | I | 1..1 | CodeableConcept | A plain text representation of the diagnosis (145 ) Binding: ICD-10-CM Diagnosis Codes (required) |
| type | I | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: Diagnosis Type -- Inpatient Facility (required) |
| onAdmission | I | 0..1 | CodeableConcept | Used to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. (28 ) Binding: NUBC Present On Admission (required) |
| procedure | I | 0..* | BackboneElement | Principal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). (24 ) |
| type | I | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example) |
| date | I | 0..1 | dateTime | When the procedure was performed |
| procedure[x] | I | 1..1 | (Slice Definition) | Specific clinical procedure Slice: Unordered, Closed by type:$this Binding: ICD-10ProcedureCodes (example) |
| insurance | ΣI | 1..* | BackboneElement | Identifies the primary payer. For use only on secondary claims. (141 ) |
| focal | ΣI | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | ΣI | 1..1 | Reference(CARIN BB Coverage) | Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1 ) |
| item | I | 0..* | BackboneElement | Product or service provided |
| sequence | I | 1..1 | positiveInt | Line identification number that represents the number assigned in a source system for identification and processing. (36 ) |
| revenue | I | 0..1 | CodeableConcept | Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86 ) Binding: nubc-service-line-revenue (required) |
| productOrService | I | 1..1 | CodeableConcept | Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40 ) Binding: AMA CPT and CMS HCPCS Procedure Codes (required) |
| modifier | I | 0..* | CodeableConcept | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41 ) Binding: AMA CPT and CMS HCPCS Modifier Codes (required) |
| quantity | I | 0..1 | SimpleQuantity | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42 ) |
| adjudication | I | 0..* | (Slice Definition) | The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149 ) Slice: Unordered, Closed by pattern:$this |
| adjudication:All Slices | Content/Rules for all slices | |||
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| adjudication:adjudicationamounttype | I | 0..* | BackboneElement | Amounts |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) |
| amount | I | 0..1 | Money | Monetary amount |
| adjudication:denialreason | I | 0..1 | BackboneElement | Denial Reason |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| adjudication:allowedunits | I | 0..1 | BackboneElement | Allowed number of units |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| adjudication | I | 0..* | (Slice Definition) | Header-level adjudication Slice: Unordered, Closed by value:category |
| adjudication:All Slices | Content/Rules for all slices | |||
| category | I | 1..1 | CodeableConcept | Indicates the in network or out of network payment status of the claim. (142 ) Binding: Claim Adjudication Category (required) |
| adjudication:adjudicationamounttype | I | 0..* | BackboneElement | Amounts |
| adjudication:denialreason | I | 0..1 | BackboneElement | Denial Reason |
| total | ΣI | 1..* | (Slice Definition) | Adjudication totals Slice: Unordered, Open by value:category |
| total:All Slices | Content/Rules for all slices | |||
| category | ΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| amount | ΣI | 1..1 | Money | Total amount for each category (i.e., submitted, allowed, etc.) (148 ) |
| total:adjudicationamounttype | ΣI | 0..* | BackboneElement | Amounts |
| amount | ΣI | 1..1 | Money | Financial total for the category |
| total:inoutnetwork | ΣI | 1..1 | BackboneElement | Benefit Payment Status |
| amount | ΣI | 1..1 | Money | Financial total for the category |
| payment | I | 0..1 | BackboneElement | Payment Details |
| type | I | 0..1 | CodeableConcept | Indicates whether the claim was paid or denied. (91 ) Binding: Claim Payment Status Code (required) |
| adjustmentReason | I | 0..1 | CodeableConcept | Reason codes used to interpret the Non-Covered Amount (92 ) Binding: PaymentAdjustmentReasonCodes (example) |
| date | I | 0..1 | date | The date the claim was paid. (107 ) |
| Documentation for this format | ||||
This structure is derived from CARINBBExplanationOfBenefit
Summary
Mandatory: 5 elements (8 nested mandatory elements)
Must-Support: 24 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from CARINBBExplanationOfBenefit
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource | |
| identifier | S | 1..* | Identifier | Claim identifier for a claim. (35 ) |
| status | S | 1..1 | code | (140 ) |
| type | 1..1 | CodeableConcept | Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). (16 ) Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional | |
| coding | S | 1..1 | Coding | Code defined by a terminology system |
| patient | 1..1 | Reference(CARIN BB Patient) | Provider submitted information that can be included on the claim (110 ) | |
| billablePeriod | 0..1 | Period | Identifies the date the patient was admitted/discharged for facility care (18,19 ) | |
| provider | 1..1 | Reference(CARIN BB Organization) | The National Provider Identifier assigned to the Billing Provider. (94 ) | |
| related | 0..* | BackboneElement | Replaced or Merged claim number (112 ) | |
| payee | ||||
| type | 1..1 | CodeableConcept | Identifies recipient of benefits payable; i.e., provider or subscriber (120 ) | |
| party | 1..1 | Reference(CARIN BB Organization | CARIN BB Patient | CARIN BB Practitioner) | Recipient reference (121 ) | |
| careTeam | I | 0..* | BackboneElement | Care Team members EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to a practitioner |
| provider | 1..1 | Reference(CARIN BB Organization | CARIN BB Practitioner) | The NPI of the referring physician. (99 ) | |
| role | 1..1 | CodeableConcept | Function within the team Binding: CARINBB Institutional Claim Care Team Roles (required) | |
| supportingInfo | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by pattern:category | |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| code | 0..1 | CodeableConcept | Patient’s status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). (117 ) | |
| supportingInfo:billingnetworkcontractingstatus | 0..1 | BackboneElement | Indicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101 ) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) | |
| supportingInfo:attendingnetworkcontractingstatus | 0..1 | BackboneElement | Indicates the network status of the attending physician (101 ) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: attendingnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) | |
| supportingInfo:referringnetworkcontractingstatus | 0..1 | BackboneElement | Indicates the network status of the referring physician (101 ) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: referringnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) | |
| supportingInfo:supervisingnetworkcontractingstatus | 0..1 | BackboneElement | Supporting information | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: supervisingnetworkcontractingstatus | |
| code | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) | |
| supportingInfo:clmrecvddate | 0..1 | BackboneElement | The date the claim was received by the payer (88 ) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
| timing[x] | 1..1 | date | When it occurred | |
| supportingInfo:typeofbill | 0..1 | BackboneElement | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17 ) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: typeofbill | |
| code | 0..1 | CodeableConcept | Type of information Binding: nubc-type-of-bill (required) | |
| supportingInfo:pointoforigin | 0..1 | BackboneElement | Identifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13 ) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admsrc | |
| code | 0..1 | CodeableConcept | Type of information Binding: nubc-admission-source (required) | |
| supportingInfo:admtype | 0..1 | BackboneElement | Claim Priority (Type) of Admission or Visit | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admtype | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Priority of Admission (required) | |
| supportingInfo:discharge-status | 0..1 | BackboneElement | Discharge Status | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: discharge-status | |
| code | 0..1 | CodeableConcept | Type of information Binding: NUBC Patient Discharge Status (required) | |
| supportingInfo:drg | 0..1 | BackboneElement | Claim diagnosis related group (DRG) | |
| category | 1..1 | CodeableConcept | Classification of the supplied information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: drg | |
| code | 0..1 | CodeableConcept | Type of information Binding: CMS-DRG (required) | |
| supportingInfo:onadmissiontype | 0..1 | BackboneElement | On Admission Type | |
| code | 0..1 | CodeableConcept | Type of information Binding: Payer Diagnosis Present On Admission Diagnosis Type (required) | |
| diagnosis | S | 1..* | BackboneElement | This is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. (31 ) |
| diagnosis[x] | S | 1..1 | CodeableConcept | A plain text representation of the diagnosis (145 ) Binding: ICD-10-CM Diagnosis Codes (required) |
| type | S | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: Diagnosis Type -- Inpatient Facility (required) |
| onAdmission | S | 0..1 | CodeableConcept | Used to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. (28 ) Binding: NUBC Present On Admission (required) |
| procedure | 0..* | BackboneElement | Principal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). (24 ) | |
| procedure[x] | S | 1..1 | (Slice Definition) | Specific clinical procedure Slice: Unordered, Open by type:$this |
| procedureCodeableConcept | 0..1 | CodeableConcept | Specific clinical procedure Binding: ICD-10-PCS (required) | |
| insurance | 1..* | BackboneElement | Identifies the primary payer. For use only on secondary claims. (141 ) | |
| coverage | 1..1 | Reference(CARIN BB Coverage) | Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1 ) | |
| item | ||||
| sequence | S | 1..1 | positiveInt | Line identification number that represents the number assigned in a source system for identification and processing. (36 ) |
| revenue | S | 0..1 | CodeableConcept | Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86 ) Binding: nubc-service-line-revenue (required) |
| productOrService | S | 1..1 | CodeableConcept | Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40 ) Binding: AMA CPT and CMS HCPCS Procedure Codes (required) |
| modifier | S | 0..* | CodeableConcept | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41 ) Binding: AMA CPT and CMS HCPCS Modifier Codes (required) |
| quantity | S | 0..1 | SimpleQuantity | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42 ) |
| adjudication | 0..* | (Slice Definition) | The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149 ) Slice: Unordered, Closed by pattern:$this | |
| adjudication:adjudicationamounttype | 0..* | BackboneElement | Amounts | |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) | |
| amount | S | 0..1 | Money | Monetary amount |
| adjudication:denialreason | 0..1 | BackboneElement | Denial Reason | |
| category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) | |
| adjudication:allowedunits | 0..1 | BackboneElement | Allowed number of units | |
| category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
| adjudication | 0..* | (Slice Definition) | Header-level adjudication Slice: Unordered, Closed by value:category | |
| adjudication:All Slices | Content/Rules for all slices | |||
| category | S | 1..1 | CodeableConcept | Indicates the in network or out of network payment status of the claim. (142 ) |
| adjudication:adjudicationamounttype | 0..* | BackboneElement | Amounts | |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) | |
| amount | 1..1 | Money | Monetary amount | |
| adjudication:denialreason | 0..1 | BackboneElement | Denial Reason | |
| category | 1..1 | CodeableConcept | Type of adjudication information Required Pattern: At least the following | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
| reason | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) | |
| total | 1..* | (Slice Definition) | Adjudication totals Slice: Unordered, Open by value:category | |
| total:All Slices | Content/Rules for all slices | |||
| category | S | 1..1 | CodeableConcept | Type of adjudication information |
| amount | S | 1..1 | Money | Total amount for each category (i.e., submitted, allowed, etc.) (148 ) |
| total:adjudicationamounttype | S | 0..* | BackboneElement | Amounts |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) | |
| amount | S | 1..1 | Money | Financial total for the category |
| total:inoutnetwork | S | 1..1 | BackboneElement | Benefit Payment Status |
| category | 1..1 | CodeableConcept | Type of adjudication information Binding: Benefit Payment Status (required) | |
| amount | S | 1..1 | Money | Financial total for the category |
| payment | ||||
| type | S | 0..1 | CodeableConcept | Indicates whether the claim was paid or denied. (91 ) |
| adjustmentReason | S | 0..1 | CodeableConcept | Reason codes used to interpret the Non-Covered Amount (92 ) |
| date | S | 0..1 | date | The date the claim was paid. (107 ) |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| ExplanationOfBenefit | I | 0..* | CARINBBExplanationOfBenefit | Explanation of Benefit resource |
| id | Σ | 0..1 | string | Logical id of this artifact |
| meta | ΣI | 0..1 | Meta | Metadata about the resource |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| versionId | ΣI | 0..1 | id | Version specific identifier |
| lastUpdated | SΣI | 1..1 | instant | When the resource version last changed |
| source | ΣI | 0..1 | uri | Identifies where the resource comes from |
| profile | SΣI | 1..* | canonical(StructureDefinition) | Profiles this resource claims to conform to |
| security | ΣI | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible) |
| tag | ΣI | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example) |
| implicitRules | ?!ΣI | 0..1 | uri | A set of rules under which this content was created |
| language | I | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| text | I | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| contained | 0..* | Resource | Contained, inline Resources | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!I | 0..* | Extension | Extensions that cannot be ignored |
| identifier | SI | 1..* | (Slice Definition) | Claim identifier for a claim. (35 ) Slice: Unordered, Open by pattern:$this |
| identifier:claimnumber | SI | 1..1 | Identifier | Claim Number Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| use | 0..1 | code | usual | official | temp | secondary | old (If known) | |
| type | 1..1 | CodeableConcept | Description of identifier Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/IdentifierTypeCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: cn | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| system | 0..1 | uri | The namespace for the identifier value | |
| value | 0..1 | string | The value that is unique | |
| period | 0..1 | Period | Time period when id is/was valid for use | |
| assigner | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| use | ?!ΣI | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required) |
| type | ΣI | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | ΣI | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | SΣI | 1..1 | string | The value that is unique Example General: 123456 |
| period | ΣI | 0..1 | Period | Time period when id is/was valid for use |
| assigner | ΣI | 0..1 | Reference(Organization) | Organization that issued id (may be just text) |
| status | ?!SΣI | 1..1 | code | (140 ) Binding: ExplanationOfBenefitStatus (required) |
| type | SΣI | 1..1 | CodeableConcept | Specifies the type of claim. (e.g., inpatient insitutional, outpatient institutional, physician, etc.). (16 ) Binding: ClaimTypeCodes (required) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://terminology.hl7.org/CodeSystem/claim-type | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: institutional | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| coding | SΣI | 1..1 | Coding | Code defined by a terminology system |
| text | ΣI | 0..1 | string | Plain text representation of the concept |
| subType | I | 0..1 | CodeableConcept | More granular claim type Binding: ExampleClaimSubTypeCodes (example) |
| use | ΣI | 1..1 | code | claim | preauthorization | predetermination Binding: Use (required) Required Pattern: claim |
| patient | SΣI | 1..1 | Reference(CARIN BB Patient) | Provider submitted information that can be included on the claim (110 ) |
| billablePeriod | SΣI | 0..1 | Period | Identifies the date the patient was admitted/discharged for facility care (18,19 ) |
| created | ΣI | 1..1 | dateTime | Response creation date |
| enterer | I | 0..1 | Reference(Practitioner | PractitionerRole) | Author of the claim |
| insurer | SΣI | 1..1 | Reference(CARIN BB Organization) | Party responsible for reimbursement |
| provider | SΣI | 1..1 | Reference(CARIN BB Organization) | The National Provider Identifier assigned to the Billing Provider. (94 ) |
| priority | I | 0..1 | CodeableConcept | Desired processing urgency Binding: http://terminology.hl7.org/CodeSystem/processpriority (example) |
| fundsReserveRequested | I | 0..1 | CodeableConcept | For whom to reserve funds Binding: Funds Reservation Codes (example) |
| fundsReserve | I | 0..1 | CodeableConcept | Funds reserved status Binding: Funds Reservation Codes (example) |
| related | SI | 0..* | BackboneElement | Replaced or Merged claim number (112 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| claim | I | 0..1 | Reference(Claim) | Reference to the related claim |
| relationship | SI | 1..1 | CodeableConcept | How the reference claim is related Binding: ExampleRelatedClaimRelationshipCodes (example) |
| reference | I | 0..1 | Identifier | File or case reference |
| prescription | I | 0..1 | Reference(MedicationRequest | VisionPrescription) | Prescription authorizing services or products |
| originalPrescription | I | 0..1 | Reference(MedicationRequest) | Original prescription if superceded by fulfiller |
| payee | SI | 0..1 | BackboneElement | Recipient of benefits payable |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | SI | 1..1 | CodeableConcept | Identifies recipient of benefits payable; i.e., provider or subscriber (120 ) Binding: Claim Payee Type Codes (example) |
| party | SI | 1..1 | Reference(CARIN BB Organization | CARIN BB Patient | CARIN BB Practitioner) | Recipient reference (121 ) |
| referral | I | 0..1 | Reference(ServiceRequest) | Treatment Referral |
| facility | I | 0..1 | Reference(Location) | Servicing Facility |
| claim | I | 0..1 | Reference(Claim) | Claim reference |
| claimResponse | I | 0..1 | Reference(ClaimResponse) | Claim response reference |
| outcome | ΣI | 1..1 | code | queued | complete | error | partial Binding: ClaimProcessingCodes (required) |
| disposition | I | 0..1 | string | Disposition Message |
| preAuthRef | I | 0..* | string | Preauthorization reference |
| preAuthRefPeriod | I | 0..* | Period | Preauthorization in-effect period |
| careTeam | SI | 0..* | BackboneElement | Care Team members EOB-inst-careTeam-practitioner: Institutional EOB: Careteam roles refer to a practitioner EOB-inst-careTeam-organization: Institutional EOB: Careteam roles refer to a practitioner |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Order of care team |
| provider | SI | 1..1 | Reference(CARIN BB Organization | CARIN BB Practitioner) | The NPI of the referring physician. (99 ) |
| responsible | SI | 0..1 | boolean | Indicator of the lead practitioner |
| role | SI | 1..1 | CodeableConcept | Function within the team Binding: CARINBB Institutional Claim Care Team Roles (required) |
| qualification | I | 0..1 | CodeableConcept | Practitioner credential or specialization Binding: ExampleProviderQualificationCodes (example) |
| supportingInfo | SI | 0..* | (Slice Definition) | Supporting information Slice: Unordered, Open by pattern:category |
| supportingInfo:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) |
| code | SI | 0..1 | CodeableConcept | Patient’s status as of the discharge date for a facility stay. Information located on UB04 (Form Locator 17). (117 ) Binding: ExceptionCodes (example) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:billingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Indicates that the Billing Provider has a contract with the Plan (regardless of the network) as of the effective date of service or admission. (101 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: billingnetworkcontractingstatus | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:attendingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Indicates the network status of the attending physician (101 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: attendingnetworkcontractingstatus | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:referringnetworkcontractingstatus | SI | 0..1 | BackboneElement | Indicates the network status of the referring physician (101 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: referringnetworkcontractingstatus | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:supervisingnetworkcontractingstatus | SI | 0..1 | BackboneElement | Supporting information |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: supervisingnetworkcontractingstatus | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 1..1 | CodeableConcept | Type of information Binding: Provider Provider Contracting Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:clmrecvddate | SI | 0..1 | BackboneElement | The date the claim was received by the payer (88 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: clmrecvddate | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: ExceptionCodes (example) |
| timing[x] | SI | 1..1 | date | When it occurred |
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:typeofbill | SI | 0..1 | BackboneElement | UB04 (Form Locator 4) type of bill code provides specific information for payer purposes. The first digit of the three-digit number denotes the type of facility, the second digit classifies the type of care being billed, and the third digit identifies the frequency of the bill for a specific course of treatment or inpatient confinement. (17 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: typeofbill | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: nubc-type-of-bill (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:pointoforigin | SI | 0..1 | BackboneElement | Identifies the place where the patient was identified as needing admission to a facility. This is a two position code mapped from the standard values for the UB-04 Source of Admission code (FL-15). (13 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admsrc | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: nubc-admission-source (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:admtype | SI | 0..1 | BackboneElement | Claim Priority (Type) of Admission or Visit |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: admtype | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Priority of Admission (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:discharge-status | SI | 0..1 | BackboneElement | Discharge Status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: discharge-status | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: NUBC Patient Discharge Status (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:drg | SI | 0..1 | BackboneElement | Claim diagnosis related group (DRG) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimInformationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: drg | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: CMS-DRG (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| supportingInfo:onadmissiontype | SI | 0..1 | BackboneElement | On Admission Type |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Information instance identifier |
| category | I | 1..1 | CodeableConcept | Classification of the supplied information Binding: ClaimInformationCategoryCodes (example) |
| code | SI | 0..1 | CodeableConcept | Type of information Binding: Payer Diagnosis Present On Admission Diagnosis Type (required) |
| timing[x] | SI | 0..1 | When it occurred | |
| timingDate | date | |||
| timingPeriod | Period | |||
| value[x] | SI | 0..1 | Data to be provided | |
| valueBoolean | boolean | |||
| valueString | string | |||
| valueQuantity | Quantity | |||
| valueAttachment | Attachment | |||
| valueReference | Reference(Resource) | |||
| reason | I | 0..1 | Coding | Explanation for the information Binding: MissingToothReasonCodes (example) |
| diagnosis | SI | 1..* | BackboneElement | This is the reason given by the patient for visiting the doctor or practitioner. It is not the doctor's or practitioner's diagnosis. Patient Reason for Visit Codes can be any ICD-10diagnosis and may or may not be a repeat of an ICD-10 Principal or Secondary diagnosis field. (31 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Diagnosis instance identifier |
| diagnosis[x] | SI | 1..1 | CodeableConcept | A plain text representation of the diagnosis (145 ) Binding: ICD-10-CM Diagnosis Codes (required) |
| type | SI | 1..1 | CodeableConcept | Timing or nature of the diagnosis Binding: Diagnosis Type -- Inpatient Facility (required) |
| onAdmission | SI | 0..1 | CodeableConcept | Used to capture whether a diagnosis was present at time of a patient's admission. This is used to group diagnoses into the proper DRG for all claims involving inpatient admissions to general acute care facilities. (28 ) Binding: NUBC Present On Admission (required) |
| packageCode | I | 0..1 | CodeableConcept | Package billing code Binding: ExampleDiagnosisRelatedGroupCodes (example) |
| procedure | SI | 0..* | BackboneElement | Principal medical procedure a patient received during inpatient stay. Coding methods for this field is International Classification of Diseases Surgical Procedures (ICD-10). (24 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Procedure instance identifier |
| type | SI | 0..* | CodeableConcept | Category of Procedure Binding: ExampleProcedureTypeCodes (example) |
| date | SI | 0..1 | dateTime | When the procedure was performed |
| procedure[x] | SI | 1..1 | (Slice Definition) | Specific clinical procedure Slice: Unordered, Closed by type:$this Binding: ICD-10ProcedureCodes (example) |
| procedure[x]:procedureCodeableConcept | I | 0..1 | CodeableConcept | Specific clinical procedure Binding: ICD-10-PCS (required) |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| precedence | I | 0..1 | positiveInt | Precedence (primary, secondary, etc.) |
| insurance | SΣI | 1..* | BackboneElement | Identifies the primary payer. For use only on secondary claims. (141 ) |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| focal | SΣI | 1..1 | boolean | Coverage to be used for adjudication |
| coverage | SΣI | 1..1 | Reference(CARIN BB Coverage) | Unique identifier for a member assigned by the Payer. If members receive ID cards, that is the identifier that should be provided. (1 ) |
| preAuthRef | I | 0..* | string | Prior authorization reference number |
| accident | I | 0..1 | BackboneElement | Details of the event |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| date | I | 0..1 | date | When the incident occurred |
| type | I | 0..1 | CodeableConcept | The nature of the accident Binding: ActIncidentCode (extensible) |
| location[x] | I | 0..1 | Where the event occurred | |
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| item | SI | 0..* | BackboneElement | Product or service provided |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | SI | 1..1 | positiveInt | Line identification number that represents the number assigned in a source system for identification and processing. (36 ) |
| careTeamSequence | I | 0..* | positiveInt | Applicable care team members |
| diagnosisSequence | I | 0..* | positiveInt | Applicable diagnoses |
| procedureSequence | I | 0..* | positiveInt | Applicable procedures |
| informationSequence | I | 0..* | positiveInt | Applicable exception and supporting information |
| revenue | SI | 0..1 | CodeableConcept | Code used on the UB-04 (Form Locator 42) to identify a specific accommodation, ancillary service, or billing calculation related to the service being billed (86 ) Binding: nubc-service-line-revenue (required) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | SI | 1..1 | CodeableConcept | Medical procedure a patient received from a health care provider. Current coding methods include: CPT-4 and HCFA Common Procedure Coding System Level II - (HCPCSII). (40 ) Binding: AMA CPT and CMS HCPCS Procedure Codes (required) |
| modifier | SI | 0..* | CodeableConcept | Modifier(s) for the procedure represented on this line. Identifies special circumstances related to the performance of the service. (41 ) Binding: AMA CPT and CMS HCPCS Modifier Codes (required) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | SI | 0..1 | SimpleQuantity | The quantity of units, times, days, visits, services, or treatments for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (42 ) |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| encounter | I | 0..* | Reference(Encounter) | Encounters related to this billed item |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | SI | 0..* | (Slice Definition) | The quantity of units, times, days, visits, services, or treatments allowed for the service described by the HCPCS code, revenue code or procedure code, submitted by the provider. (149 ) Slice: Unordered, Closed by pattern:$this |
| adjudication:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:adjudicationamounttype | SI | 0..* | BackboneElement | Amounts |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | SI | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:denialreason | SI | 0..1 | BackboneElement | Denial Reason |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| reason | I | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:allowedunits | SI | 0..1 | BackboneElement | Allowed number of units |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: allowedunits | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| detail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Detail level adjudication details |
| subDetail | I | 0..* | BackboneElement | Additional items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| sequence | I | 1..1 | positiveInt | Product or service provided |
| revenue | I | 0..1 | CodeableConcept | Revenue or cost center code Binding: ExampleRevenueCenterCodes (example) |
| category | I | 0..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| udi | I | 0..* | Reference(Device) | Unique device identifier |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Subdetail level adjudication details |
| addItem | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| itemSequence | I | 0..* | positiveInt | Item sequence number |
| detailSequence | I | 0..* | positiveInt | Detail sequence number |
| subDetailSequence | I | 0..* | positiveInt | Subdetail sequence number |
| provider | I | 0..* | Reference(Practitioner | PractitionerRole | Organization) | Authorized providers |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| programCode | I | 0..* | CodeableConcept | Program the product or service is provided under Binding: ExampleProgramReasonCodes (example) |
| serviced[x] | I | 0..1 | Date or dates of service or product delivery | |
| servicedDate | date | |||
| servicedPeriod | Period | |||
| location[x] | I | 0..1 | Place of service or where product was supplied Binding: ExampleServicePlaceCodes (example) | |
| locationCodeableConcept | CodeableConcept | |||
| locationAddress | Address | |||
| locationReference | Reference(Location) | |||
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| bodySite | I | 0..1 | CodeableConcept | Anatomical location Binding: OralSiteCodes (example) |
| subSite | I | 0..* | CodeableConcept | Anatomical sub-location Binding: SurfaceCodes (example) |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| detail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| subDetail | I | 0..* | BackboneElement | Insurer added line items |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| productOrService | I | 1..1 | CodeableConcept | Billing, service, product, or drug code Binding: USCLSCodes (example) |
| modifier | I | 0..* | CodeableConcept | Service/Product billing modifiers Binding: ModifierTypeCodes (example) |
| quantity | I | 0..1 | SimpleQuantity | Count of products or services |
| unitPrice | I | 0..1 | Money | Fee, charge or cost per item |
| factor | I | 0..1 | decimal | Price scaling factor |
| net | I | 0..1 | Money | Total item cost |
| noteNumber | I | 0..* | positiveInt | Applicable note numbers |
| adjudication | I | 0..* | See adjudication | Added items adjudication |
| adjudication | SI | 0..* | (Slice Definition) | Header-level adjudication Slice: Unordered, Closed by value:category |
| adjudication:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SI | 1..1 | CodeableConcept | Indicates the in network or out of network payment status of the claim. (142 ) Binding: Claim Adjudication Category (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:adjudicationamounttype | SI | 0..* | BackboneElement | Amounts |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) |
| reason | I | 0..1 | CodeableConcept | Explanation of adjudication outcome Binding: AdjudicationReasonCodes (example) |
| amount | I | 1..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| adjudication:denialreason | SI | 0..1 | BackboneElement | Denial Reason |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) Required Pattern: At least the following |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| coding | 1..* | Coding | Code defined by a terminology system Fixed Value: (complex) | |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | 0..* | Extension | Additional content defined by implementations | |
| system | 1..1 | uri | Identity of the terminology system Fixed Value: http://hl7.org/fhir/us/carin-bb/CodeSystem/ClaimAdjudicationCategoryCS | |
| version | 0..1 | string | Version of the system - if relevant | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: denialreason | |
| display | 0..1 | string | Representation defined by the system | |
| userSelected | 0..1 | boolean | If this coding was chosen directly by the user | |
| text | 0..1 | string | Plain text representation of the concept | |
| reason | I | 1..1 | CodeableConcept | Explanation of adjudication outcome Binding: Adjudication Denial Reason (required) |
| amount | I | 0..1 | Money | Monetary amount |
| value | I | 0..1 | decimal | Non-monitary value |
| total | ΣI | 1..* | (Slice Definition) | Adjudication totals Slice: Unordered, Open by value:category |
| total:All Slices | Content/Rules for all slices | |||
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | SΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: Claim Adjudication Category (required) |
| amount | SΣI | 1..1 | Money | Total amount for each category (i.e., submitted, allowed, etc.) (148 ) |
| total:adjudicationamounttype | SΣI | 0..* | BackboneElement | Amounts |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | ΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: Adjudication CARINBB Value Codes (required) |
| amount | SΣI | 1..1 | Money | Financial total for the category |
| total:inoutnetwork | SΣI | 1..1 | BackboneElement | Benefit Payment Status |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | ΣI | 1..1 | CodeableConcept | Type of adjudication information Binding: Benefit Payment Status (required) |
| amount | SΣI | 1..1 | Money | Financial total for the category |
| payment | SI | 0..1 | BackboneElement | Payment Details |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | SI | 0..1 | CodeableConcept | Indicates whether the claim was paid or denied. (91 ) Binding: Claim Payment Status Code (required) |
| adjustment | I | 0..1 | Money | Payment adjustment for non-claim issues |
| adjustmentReason | SI | 0..1 | CodeableConcept | Reason codes used to interpret the Non-Covered Amount (92 ) Binding: PaymentAdjustmentReasonCodes (example) |
| date | SI | 0..1 | date | The date the claim was paid. (107 ) |
| amount | I | 0..1 | Money | Payable amount after adjustment |
| identifier | I | 0..1 | Identifier | Business identifier for the payment |
| formCode | I | 0..1 | CodeableConcept | Printed form identifier Binding: Form Codes (example) |
| form | I | 0..1 | Attachment | Printed reference or actual form |
| processNote | I | 0..* | BackboneElement | Note concerning adjudication |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| number | I | 0..1 | positiveInt | Note instance identifier |
| type | I | 0..1 | code | display | print | printoper Binding: NoteType (required) |
| text | I | 0..1 | string | Note explanatory text |
| language | I | 0..1 | CodeableConcept | Language of the text Binding: CommonLanguages (preferred) Max Binding: AllLanguages |
| benefitPeriod | I | 0..1 | Period | When the benefits are applicable |
| benefitBalance | I | 0..* | BackboneElement | Balance by Benefit Category |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| category | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitCategoryCodes (example) |
| excluded | I | 0..1 | boolean | Excluded from the plan |
| name | I | 0..1 | string | Short name for the benefit |
| description | I | 0..1 | string | Description of the benefit or services covered |
| network | I | 0..1 | CodeableConcept | In or out of network Binding: NetworkTypeCodes (example) |
| unit | I | 0..1 | CodeableConcept | Individual or family Binding: UnitTypeCodes (example) |
| term | I | 0..1 | CodeableConcept | Annual or lifetime Binding: BenefitTermCodes (example) |
| financial | I | 0..* | BackboneElement | Benefit Summary |
| id | 0..1 | string | Unique id for inter-element referencing | |
| extension | I | 0..* | Extension | Additional content defined by implementations |
| modifierExtension | ?!ΣI | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| type | I | 1..1 | CodeableConcept | Benefit classification Binding: BenefitTypeCodes (example) |
| allowed[x] | I | 0..1 | Benefits allowed | |
| allowedUnsignedInt | unsignedInt | |||
| allowedString | string | |||
| allowedMoney | Money | |||
| used[x] | I | 0..1 | Benefits used | |
| usedUnsignedInt | unsignedInt | |||
| usedMoney | Money | |||
| Documentation for this format | ||||
Other representations of profile: Schematron
| Path | Conformance | ValueSet / Code |
| ExplanationOfBenefit.meta.security | extensible | All Security Labels |
| ExplanationOfBenefit.meta.tag | example | CommonTags |
| ExplanationOfBenefit.language | preferred | CommonLanguages Max Binding: AllLanguages |
| ExplanationOfBenefit.identifier:claimnumber.use | required | IdentifierUse |
| ExplanationOfBenefit.identifier:claimnumber.type | extensible | Identifier Type Codes |
| ExplanationOfBenefit.status | required | ExplanationOfBenefitStatus |
| ExplanationOfBenefit.type | required | Pattern: institutional |
| ExplanationOfBenefit.subType | example | ExampleClaimSubTypeCodes |
| ExplanationOfBenefit.use | required | Pattern: claim |
| ExplanationOfBenefit.priority | example | http://terminology.hl7.org/CodeSystem/processpriority |
| ExplanationOfBenefit.fundsReserveRequested | example | Funds Reservation Codes |
| ExplanationOfBenefit.fundsReserve | example | Funds Reservation Codes |
| ExplanationOfBenefit.related.relationship | example | ExampleRelatedClaimRelationshipCodes |
| ExplanationOfBenefit.payee.type | example | Claim Payee Type Codes |
| ExplanationOfBenefit.outcome | required | ClaimProcessingCodes |
| ExplanationOfBenefit.careTeam.role | required | CARINBBInstitutionalClaimCareTeamRoleCodes |
| ExplanationOfBenefit.careTeam.qualification | example | ExampleProviderQualificationCodes |
| ExplanationOfBenefit.supportingInfo.category | example | ClaimInformationCategoryCodes |
| ExplanationOfBenefit.supportingInfo.code | example | ExceptionCodes |
| ExplanationOfBenefit.supportingInfo.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.category | example | Pattern: billingnetworkcontractingstatus |
| ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.code | required | PayerProviderContractingStatus |
| ExplanationOfBenefit.supportingInfo:billingnetworkcontractingstatus.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:attendingnetworkcontractingstatus.category | example | Pattern: attendingnetworkcontractingstatus |
| ExplanationOfBenefit.supportingInfo:attendingnetworkcontractingstatus.code | required | PayerProviderContractingStatus |
| ExplanationOfBenefit.supportingInfo:attendingnetworkcontractingstatus.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:referringnetworkcontractingstatus.category | example | Pattern: referringnetworkcontractingstatus |
| ExplanationOfBenefit.supportingInfo:referringnetworkcontractingstatus.code | required | PayerProviderContractingStatus |
| ExplanationOfBenefit.supportingInfo:referringnetworkcontractingstatus.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:supervisingnetworkcontractingstatus.category | example | Pattern: supervisingnetworkcontractingstatus |
| ExplanationOfBenefit.supportingInfo:supervisingnetworkcontractingstatus.code | required | PayerProviderContractingStatus |
| ExplanationOfBenefit.supportingInfo:supervisingnetworkcontractingstatus.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:clmrecvddate.category | example | Pattern: clmrecvddate |
| ExplanationOfBenefit.supportingInfo:clmrecvddate.code | example | ExceptionCodes |
| ExplanationOfBenefit.supportingInfo:clmrecvddate.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:typeofbill.category | example | Pattern: typeofbill |
| ExplanationOfBenefit.supportingInfo:typeofbill.code | required | http://hl7.org/fhir/ValueSet/nubc-type-of-bill |
| ExplanationOfBenefit.supportingInfo:typeofbill.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:pointoforigin.category | example | Pattern: admsrc |
| ExplanationOfBenefit.supportingInfo:pointoforigin.code | required | http://hl7.org/fhir/ValueSet/nubc-admission-source |
| ExplanationOfBenefit.supportingInfo:pointoforigin.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:admtype.category | example | Pattern: admtype |
| ExplanationOfBenefit.supportingInfo:admtype.code | required | NUBCPriorityOfAdmissionn |
| ExplanationOfBenefit.supportingInfo:admtype.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:discharge-status.category | example | Pattern: discharge-status |
| ExplanationOfBenefit.supportingInfo:discharge-status.code | required | NUBCPatientDischargeStatus |
| ExplanationOfBenefit.supportingInfo:discharge-status.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:drg.category | example | Pattern: drg |
| ExplanationOfBenefit.supportingInfo:drg.code | required | CMSDRG |
| ExplanationOfBenefit.supportingInfo:drg.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.supportingInfo:onadmissiontype.category | example | ClaimInformationCategoryCodes |
| ExplanationOfBenefit.supportingInfo:onadmissiontype.code | required | PayerDiagnosisPresentOnAdmissionDiagnosisType |
| ExplanationOfBenefit.supportingInfo:onadmissiontype.reason | example | MissingToothReasonCodes |
| ExplanationOfBenefit.diagnosis.diagnosis[x] | required | ICD10CM |
| ExplanationOfBenefit.diagnosis.type | required | PayerInpatientfacilitydiagnosistype |
| ExplanationOfBenefit.diagnosis.onAdmission | required | NUBCPresentOnAdmission |
| ExplanationOfBenefit.diagnosis.packageCode | example | ExampleDiagnosisRelatedGroupCodes |
| ExplanationOfBenefit.procedure.type | example | ExampleProcedureTypeCodes |
| ExplanationOfBenefit.procedure.procedure[x] | example | ICD-10ProcedureCodes |
| ExplanationOfBenefit.procedure.procedure[x]:procedureCodeableConcept | required | ICD10PCS |
| ExplanationOfBenefit.accident.type | extensible | ActIncidentCode |
| ExplanationOfBenefit.item.revenue | required | http://hl7.org/fhir/ValueSet/nubc-service-line-revenue |
| ExplanationOfBenefit.item.category | example | BenefitCategoryCodes |
| ExplanationOfBenefit.item.productOrService | required | AMACPTCMSHCPCSProcedureCodes |
| ExplanationOfBenefit.item.modifier | required | AMACPTCMSHCPCSProcedureModifiers |
| ExplanationOfBenefit.item.programCode | example | ExampleProgramReasonCodes |
| ExplanationOfBenefit.item.location[x] | example | ExampleServicePlaceCodes |
| ExplanationOfBenefit.item.bodySite | example | OralSiteCodes |
| ExplanationOfBenefit.item.subSite | example | SurfaceCodes |
| ExplanationOfBenefit.item.adjudication.category | required | ClaimAdjudicationCategory |
| ExplanationOfBenefit.item.adjudication.reason | example | AdjudicationReasonCodes |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.category | required | AdjudicationCarinBBValueCodes |
| ExplanationOfBenefit.item.adjudication:adjudicationamounttype.reason | example | AdjudicationReasonCodes |
| ExplanationOfBenefit.item.adjudication:denialreason.category | required | Pattern: denialreason |
| ExplanationOfBenefit.item.adjudication:denialreason.reason | required | AdjudicationDenialReason |
| ExplanationOfBenefit.item.adjudication:allowedunits.category | required | Pattern: allowedunits |
| ExplanationOfBenefit.item.adjudication:allowedunits.reason | example | AdjudicationReasonCodes |
| ExplanationOfBenefit.item.detail.revenue | example | ExampleRevenueCenterCodes |
| ExplanationOfBenefit.item.detail.category | example | BenefitCategoryCodes |
| ExplanationOfBenefit.item.detail.productOrService | example | USCLSCodes |
| ExplanationOfBenefit.item.detail.modifier | example | ModifierTypeCodes |
| ExplanationOfBenefit.item.detail.programCode | example | ExampleProgramReasonCodes |
| ExplanationOfBenefit.item.detail.subDetail.revenue | example | ExampleRevenueCenterCodes |
| ExplanationOfBenefit.item.detail.subDetail.category | example | BenefitCategoryCodes |
| ExplanationOfBenefit.item.detail.subDetail.productOrService | example | USCLSCodes |
| ExplanationOfBenefit.item.detail.subDetail.modifier | example | ModifierTypeCodes |
| ExplanationOfBenefit.item.detail.subDetail.programCode | example | ExampleProgramReasonCodes |
| ExplanationOfBenefit.addItem.productOrService | example | USCLSCodes |
| ExplanationOfBenefit.addItem.modifier | example | ModifierTypeCodes |
| ExplanationOfBenefit.addItem.programCode | example | ExampleProgramReasonCodes |
| ExplanationOfBenefit.addItem.location[x] | example | ExampleServicePlaceCodes |
| ExplanationOfBenefit.addItem.bodySite | example | OralSiteCodes |
| ExplanationOfBenefit.addItem.subSite | example | SurfaceCodes |
| ExplanationOfBenefit.addItem.detail.productOrService | example | USCLSCodes |
| ExplanationOfBenefit.addItem.detail.modifier | example | ModifierTypeCodes |
| ExplanationOfBenefit.addItem.detail.subDetail.productOrService | example | USCLSCodes |
| ExplanationOfBenefit.addItem.detail.subDetail.modifier | example | ModifierTypeCodes |
| ExplanationOfBenefit.adjudication.category | required | ClaimAdjudicationCategory |
| ExplanationOfBenefit.adjudication.reason | example | AdjudicationReasonCodes |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.category | required | AdjudicationCarinBBValueCodes |
| ExplanationOfBenefit.adjudication:adjudicationamounttype.reason | example | AdjudicationReasonCodes |
| ExplanationOfBenefit.adjudication:denialreason.category | required | Pattern: denialreason |
| ExplanationOfBenefit.adjudication:denialreason.reason | required | AdjudicationDenialReason |
| ExplanationOfBenefit.total.category | required | ClaimAdjudicationCategory |
| ExplanationOfBenefit.total:adjudicationamounttype.category | required | AdjudicationCarinBBValueCodes |
| ExplanationOfBenefit.total:inoutnetwork.category | required | BenefitPaymentStatus |
| ExplanationOfBenefit.payment.type | required | ClaimPaymentStatusCode |
| ExplanationOfBenefit.payment.adjustmentReason | example | PaymentAdjustmentReasonCodes |
| ExplanationOfBenefit.formCode | example | Form Codes |
| ExplanationOfBenefit.processNote.type | required | NoteType |
| ExplanationOfBenefit.processNote.language | preferred | CommonLanguages Max Binding: AllLanguages |
| ExplanationOfBenefit.benefitBalance.category | example | BenefitCategoryCodes |
| ExplanationOfBenefit.benefitBalance.network | example | NetworkTypeCodes |
| ExplanationOfBenefit.benefitBalance.unit | example | UnitTypeCodes |
| ExplanationOfBenefit.benefitBalance.term | example | BenefitTermCodes |
| ExplanationOfBenefit.benefitBalance.financial.type | example | BenefitTypeCodes |
| Id | Path | Details | Requirements |
| EOB-inst-careTeam-practitioner | ExplanationOfBenefit.careTeam | Institutional EOB: Careteam roles refer to a practitioner : ( careTeam.role.coding.code in ('attending' or 'pcp' or 'referring' or 'supervising')) implies careTeam.provider.reference.resolve().is(FHIR.Practitioner) | |
| EOB-inst-careTeam-organization | ExplanationOfBenefit.careTeam | Institutional EOB: Careteam roles refer to a practitioner : ( careTeam.role.coding.code='performing') implies careTeam.provider.reference.resolve().is(FHIR.Organization) |
IG © 2020+ HL7 Financial Management Working Group. Package hl7.fhir.us.carin-bb#0.4.0 based on FHIR 4.0.1. Generated 2020-08-06
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